Download Oral care

Oral care
in children undergoing
HSCT
G .Marco Deiana
Children’s Hospital G.Gaslini, Genoa, Italy.
On behalf of Paediatric Committee EBMT Nurses Group
Eugenia trigoso, Merja Stenvall, Marco Deiana
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Background
The oral cavity is very sensitive to the
toxicity of antineoplastic agents.
The incidence of oral problems varies
30 to 100% of patients
70–85% patients undergoing myeloablative HSCT
The most frequent problems are
• mucositis,
• taste changes,
• xerostomia,
• opportunistic infections,
• pain
• bleeding
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Objective
To Evaluate the importance of
oral care
To make the point about :
what it means
tools
drugs
methods
for reducing
problems
originating from the oral cavity
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Method
•review of recent literature (English)
(last 5 years until September 2010
•Medline databank
Keywords: oral care, mucositis, stem cell /bone marrow transplantation
•Analysis of the presentations of EBMT meetings.
where oral problems and care in HSCT
were the main focus
I collected 56 useful works
9 reviews
10 paediatric or mixed patients
•organization of items in an Excel file
•Data analysis
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Review - Limits
•
•
•
•
•
few pediatric studies
some studies with small populations
different methods of assessment
difficult to "weigh"the results of single study
inability sometime to identify the bias
these limits were found in all the reviews that I have analyzed
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Review
three key areas
• Methods of oral assessment
• Drugs and therapies
• Dental care and basic oral cavity hygiene
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Assessment
Oral care
• Assessment instrument
• Continuity in documentation
• Pictures of oral cavity to mark areas that are affected
• Rules of oral cavity inspection
• Trained personnel
• Multidisciplinary team
• Involve patients
Monica Fliedner, MSN ANP Oncology, Bern University Hospital (CH)- EBMT AMNG- 2010 - Vienna
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Assessment
• Clinical assessment instruments
• World Health Organisation (WHO)
• National Cancer Institute (NCI)
•Oral Assessment Guide (OAG)
•Oral Mucositis Index (OMI)
•Oral Mucositis Assessment Scale (OMAS)
• Nijmegen Nursing Mucositis Scoring System (NNMSS)
•Visual Analogue Scale (VAS)
Monica Fliedner, MSN ANP Oncology, Bern University Hospital (CH)- EBMT AMNG- 2010 - Vienna
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Assessment
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Assessment
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Assessment
• Supportive
Recommendations for clinical practice
•
Documentation of any changes
necessary!)
• Identification of risk patients
(basic
assessment
• Define how often assessment should be done
• Guideline for preventive and therapeutic measures, e.g.
-No irritating mouthwashes, keep oral cavity moist!
-Good oral hygiene with soft tooth brush
-Dental floss (cave: contraindications)
• Multidisciplinary team approach
(MASCC = Multinational Association of Supportive Care in Cancer), McGuire et al (2006)
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Assessment
No studies for
the most appropriate timing or frequency of oral assessment,
who should conduct the oral assessment and
what instruments should be used during the assessment.
Similarly, the acceptability of the assessment process to the children/teenagers was
not addressed in the literature.
UKCCSG-PONF Mouth Care Group -
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Assessment
Twenty-seven individual oral assessment tools were identified.
Twelve tools required the calculation of a compound score
two tools required complex calculations to be carried out,
only one tool was identified by the Guideline Development Group as being appropriate for
use in children, both for clinical practice and research purposes.
UKCCSG-PONF Mouth Care Group -
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Assessment
The Oral Assessment Guide (OAG) produced by Eilers et al. was considered to be user friendly and appropriate for
everyday clinical practice with both adults and children, as well as a useful research tool. It has been shown to have good
nurse/nurse, nurse/dental hygienist and nurse/dentist inter-rater reliability.
UKCCSG-PONF Mouth Care Group -
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Assessment
RECOMMENDATIONS FOR ORAL ASSESSMENT DURING CANCER
TREATMENT OF CHILDREN
-
The Eilers’ Oral Assessment Guide
offers a valid, reliable and clinically useful tool for assessing oral status.
The adaptation is recommended for use in children and young people.
-responsible for assessment
-Nursing staff
should be appropriately trained
are best placed for the regular assessment of the
child’s oral status.
UKCCSG-PONF Mouth Care Group
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Assessment
Oral assessment has not always been
consistently
and accurately assessed,
therefore mucositis may be
underreported
and undertreated.
POMA training demonstrates that appropriate education can help the SCT team achieve
consistent OM assessment.
The multidisciplinary nursing, physician, and dentist Mucositis Advisory Group
plan to extend OM training to centres not involved in POMA
in an effort to standardize OM assessment throughout Europe, thereby leading to improved
patient care.
EBMT Mucositis Advisory Group
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Drugs, therapies and other
More than
85 drugs and therapies
(or combinations)
have been tried
to solve or minimize
oral cavity health problems
of patients undergoing HSCT.
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Drugs, therapies and other
Acyclovir
Allopurinol mouthwash
Aloa vera
Amifostine
amino acids
Amphotericin B
Antiseptic and Antimicrobial Agents
(topic)
Anti-inflammatory rinses
Antibiotic pastille or paste versus
placebo
Azelastine
Bacitracin,
clotrinazole,
gentamicin (BcoG lozenges)
Benzydamine
Beta carotene versus no treatment
control
Biperidine
Budesonide
Calcium phosphate
carob versus Chlorhexidine
and Nistatin plus carob
Chamomille
Chaposol
Chypotrypsin
Chinese medicine
Chlorhexidine
Ciclosporine
Clopidogrel
Clotrimazole
Coumarin / Troxerutine
Episil plus cryotherapy
Fluconazole
Folinic acid
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Drugs, therapies and other
G-CSF
Gealclair
Glutamine
GM-CSF
Histamine gel versus placebo
Honey
Hydrolytic enzymes
Ice chips
Ice chip plus propantheline
Immunoglobulin
Interleukin -1
Interleukin-11
Iseganan
Itraconazole
Keratinocyte GF
Ketocolnazole
Magic (lidocaine solution, diphenhydramine
hydrochloride and aluminium hydroxide
suspension )
Manganese superoxide dismutase (detoxifies ROS)
Miconazole
Misonidazole
Misoprostol
Mucotrol extracts from licorice root and aloe vera
Na-sucrose gel
N-Acetyl Cysteine
Natamycin
Norfloxacin plus amphoterecin B
nystatin
nystatin plus chlorhexidine
nystatin plus amphoterecin B
Omega 3
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Drugs, therapies and other
Oral care versus no treatment or limited oral
hygiene
Assessment of the nurses
Papain
Pegfilgrastim versus filgrastim
Pentoxifylline
Pilocarpine
Povidone
Iodine
Prednisone versus placebo
Propantheline versus placebo
Prostaglandin versus placebo
Protegrin Peptides
PTA : Polymyxin E, tobramycin, Amphotericin
paste
Sodium bicarbonate
Sucralfate versus placebo
Systemic antibiotic clarithromycin
versus no treatment
Talidomide
TGF-beta 3
Thymostimulin
Traumeel versus placebo
Tretinoin
Trypsin
Vitamin E
Zinc sulphate
Laser therapy
tramadole and buprenorphin in advance
Vitamin E
hyaluronic acid
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Dental care
and basic oral cavity hygiene
Younger patients present
more oral problems than adults
there are many oncology and HCT protocols
every patient should be managed on an individual basis and appropriate consultations with
physicians and other dental specialists
These patients should be treated within the National Health Service
It should be to establish a register of dental problems in pediatric patients with cancer.
1.
1.
Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell Transplantation, and/or Radiation cancer therapies
in the oral cavity.
American academy of Pediatric dentistry
Linee guida per la promozione della salute orale e la prevenzione delle patologie orali negli individui in età evolutiva che devono essere sottoposti
a terapia chemio e/o radio.
Ministero della Salute Italiano
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Dental care and basic oral cavity hygiene
Before therapy
Objectives
To
identify
and stabilize
or eliminate
existing and potential sources of infection and local irritants in the oral cavity
without needlessly delaying the cancer treatment or inducing complications
Patients
to educate
parents
1.
importance of optimal oral care
Before
During
After treatment
Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell Transplantation, and/or Radiation cancer therapies
in the oral cavity.
American academy of Pediatric dentistry
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Dental care and basic oral cavity hygiene
Before therapy
EDUCATION
It is recommended brushing teeth at least twice a day with a quantity of fluoride toothpaste
according to age
toothbrush, for the exclusive use of the child, must be changed every three months, or replaced
after each episode of infection that has interested in the oral cavity.
For infants, parents should be educated on how to clean the mucosa with a gauze /
nonwovens.
The use of additional tools (dental floss, etc) and applications of topical fluoride should be
prescribed by a dental
1.
2.
Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell Transplantation, and/or Radiation cancer therapies
in the oral cavity.
American academy of Pediatric dentistry
Linee guida per la promozione della salute orale e la prevenzione delle patologie orali negli individui in età evolutiva che devono essere sottoposti
a terapia chemio e/o radio.
Ministero della Salute Italiano
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Dental care and basic oral cavity hygiene
Before therapy - prevention of oral mucositis
The following principles and pharmacological compounds have shown a potential benefit in preventing mucositis in adult
patients:
Amifostine, Benzodiamina, calcium phosphate,
honey, hydrolytic enzymes, zinc sulfate,
For the prevention of mucositis secondary to chemo-radio therapy, there is no scientific evidence to recommend the use of the
following active ingredients:
Allopurinol, aloe vera, bacitracin, gentamicin,
beta carotene, chamomile, clarithromycin.
The use of antifungal prophylaxis is indicated if there is a high risk for the patient to develop a systemic infection.
The scarcity of scientific evidence on the patient in childhood, does not allow a strong recommendation
Their use in children for the prevention of radiotherapy and/or chemotherapy induced mucositis can only be considered
within the constraints of an RCT
- Mouth Care for Children and Young People with Cancer: Evidence-based Guidelines 2UKCCSG-PONF Mouth Care Group
- Linee guida per la promozione della salute orale e la prevenzione delle patologie orali negli individui in età evolutiva che devono essere sottoposti a terapia chemio e/o radio.
Ministero della Salute Italiano
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Dental care and basic oral cavity hygiene
During treatment
Dental and oral care during immunosupression periods
The objectives of a dental/oral care during cancer therapy are three-fold:
1.
to maintain optimal oral health during cancer therapy;
2. to manage any oral side effects that may develop as a consequence of the cancer therapy;
3. to reinforce the patient and parents’ education regarding the importance of optimal oral care in
order to minimize oral problems/discomfort during treatment.
Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell Transplantation,
and/or Radiation cancer therapies in the oral cavity.
American academy of Pediatric dentistry
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Dental care and basic oral cavity hygiene
During treatment
•For severe mucositis
foam brushes or super soft
brushes soaked in chlorhexidine
•Otherwise, foam or super soft brushes should be discouraged because they
do not allow for effective cleaning
• Electric or ultrasonic brushes are acceptable if the patient is capable of using
them without causing trauma and irritation.
Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell Transplantation,
and/or Radiation cancer therapies in the oral cavity.
American academy of Pediatric dentistry
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Dental care and basic oral cavity hygiene
During treatment
Diet:
Fluoride:
non-cariogenic diet
high risk of dietary supplements rich in carbohydrate
and oral pediatric medications rich in sucrose
fluoridated toothpaste
fluoride supplements if indicated
neutral fluoride gels/rinses
or applications of fluoride varnish
for patients at risk for caries and/or xerostomia
A brush-on technique is convenient, familiar, and simple and may increase the likelihood of patient compliance with
topical fluoride therapy
Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell Transplantation,
and/or Radiation cancer therapies in the oral cavity.
American academy of Pediatric dentistry
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Dental care and basic oral cavity hygiene
During treatment
Lip care:
Education:
Dental care:
Lanolin-based creams
reinforcing the importance of optimal oral hygiene
possible acute and long-term effects of the therapy in the craniofacial complex.
elective dental care must not be provided
If a dental emergency arises
the treatment plan should be discussed with the patient’s physician
who will make recommendations for supportive medical therapies
(eg, antibiotics, platelet transfusions, analgesia).
Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell Transplantation,
and/or Radiation cancer therapies in the oral cavity.
American academy of Pediatric dentistry
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Dental care and basic oral cavity hygiene
During treatment
Oral hygiene advice
should be provided both verbally and in writing
should be given by a designated member of the dental team
or, member of the medical or nursing team
who has received appropriate training.
Mouth Care for Children and Young People with Cancer: evidence-based Guidelines - UKCCSG-PONF Mouth Care Group
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Dental care and basic oral cavity hygiene
During treatment
Oral hygiene advice
to brush at least twice a day
fluoride toothpaste (containing 1,000 ppm fluoride +/- 10%).
toothbrush
sole use of the child
Changed
on a 3 monthly basis
when bristles splay
following an oral infective episode.
If the child has a sore mouth
a soft brush with a small head should be used.
Mouth Care for Children and Young People with Cancer: evidence-based Guidelines - UKCCSG-PONF Mouth Care Group
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Dental care and basic oral cavity hygiene
During treatment
For children up to the age of 6 years,
parents/carers should be instructed on how to brush their child’s teeth.
For babies without teeth,
parents/carers should be instructed on how to clean the mouth with oral sponges.
The sponge should be moistened with water.
For children where it is not possible to brush teeth
parents/carers should be instructed on how to clean the mouth with oral sponges
as a temporary measure
The sponge should be moistened with water or an antimicrobial agent such as diluted chlorhexidine.
Additional aids, such as flossing and fluoride supplements should only be prescribed according to risk assessment by a
member of the dental team.
The need to restrict sugary food and drink to meal times only should be emphasised.
Mouth Care for Children and Young People with Cancer: evidence-based Guidelines - UKCCSG-PONF Mouth Care Group
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Dental care and basic oral cavity hygiene
During treatment – drugs and other
The following have all been shown to be
potentially beneficial for the prevention of mucositis in adult populations
Their use in children for the prevention of radiotherapy and/or chemotherapy induced mucositis
can only be considered within the constraints of an RCT
Amifostine
GM-CSF/G-CSF
Allopurinol mouthwash (for 5-FU therapy)
Benzydamine
Antibiotic pastilles/pastes (containing polymyxin E,
Ice-chips
Povidone-iodine
tobramycin and amphotericin (PTA))
Pilocarpine (not currently available in a form suitable for children)
Hydrolytic enzymes.
Mouth Care for Children and Young People with Cancer: evidence-based Guidelines - UKCCSG-PONF Mouth Care Group
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Dental care and basic oral cavity hygiene
During treatment – drugs and other
The administration of opiates
in pain control is recommended.
Taking ice before bolus chemotherapy
reduces the absorption of chemotherapeutic
The use of chlorhexidine is not recommended
for mucositis in pediatric patients
because of its typical side effects (burning and dysgeusia)
The use of local anesthetics such as viscous lidocaine
followed by non-steroidal anti-inflammatory agents
can be recommended to reduce pain in mucositis.
Posts with the soft laser
may be indicated in cases of ulcerative mucositis and refractory
1.
Linee guida per la promozione della salute orale e la prevenzione delle patologie orali negli individui in età evolutiva che devono
essere sottoposti a terapia chemio e/o radio.
Ministero della Salute Italiano June 2010
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Dental care and basic oral cavity hygiene
During treatment – drugs and other
Expert Opinion
Bland Rinses
Rinses are used to remove loose debris and aid with oral hydration.
Bland rinses
include 0.9% saline (normal saline),
sodium bicarbonate
, and a saline and sodium bicarbonate mixture.
Typical mixtures contain one teaspoon salt or sodium bicarbonate per pint of water.
Any of those rinses can be administered at room temperature or refrigerated, and all are inexpensive.
Patients should be instructed to take a tablespoon of the rinse, swish it in the oral cavity for at least 30 seconds, and
expectorate.
Sodium bicarbonate reduces the acidity of oral fluids,
(Dodd et al., 2000; Eilers, 2004; Rubenstein et al., 2004; Scully et al., 2006; Shih et al., 2002).
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Dental care and basic oral cavity hygiene
After HSCT
The objectives of a dental/oral examination after cancer therapy ends are :
to maintain optimal oral health
to reinforce to the patient/parents
the importance of optimal oral and dental care
for life
Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell Transplantation,
and/or Radiation cancer therapies in the oral cavity.
American academy of Pediatric dentistry
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Dental care and basic oral cavity hygiene
After HSCT
Oral hygiene:
Diet:
Patients must brush their teeth 2 to 3 times daily with a soft nylon toothbrush.
Brushes should be airdried between uses.
Patients should floss daily.
Dental practitioners should encourage a non-cariogenic diet
and advise patients/parents about the high cariogenic potential of dietary supplements rich in
carbohydrate and oral pediatric medications rich in sucrose.
Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell Transplantation,
and/or Radiation cancer therapies in the oral cavity.
American academy of Pediatric dentistry
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Dental care and basic oral cavity hygiene
After HSCT
Fluoride:
use of fluoridated toothpaste,
fluoride supplements if indicated,
neutral fluoride gels/rinses,
or applications of fluoride varnish
for patients at risk for caries and/or xerostomia.
A brush-on technique is convenient, familiar, and simple and may increase the likelihood of patient compliance with topical
fluoride therapy.
Lip care:
Lanolin-based creams and ointments
are more effective in moisturizing and protecting
against damage than petrolatum-based products.
Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell Transplantation,
and/or Radiation cancer therapies in the oral cavity.
American academy of Pediatric dentistry
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Dental care and basic oral cavity hygiene
After HSCT
Education:
reinforce
to emphasize the need for regular follow-ups with a dental professional
risk for or have developed.
at least every 6 months
or in shorter intervals
Periodic evaluation:
if issues such as chronic oral GVHD, xerostomia, or trismus are present
Patients who have experienced moderate or severe mucositis and/or chronic oral GVHD
should be followed closely
for malignant transformation of their oral mucosa
(eg, oral squamous cell carcinoma).
Orthodontic treatment:
after completion of all therapy
after at least a 2 year disease-free survival
when the risk of relapse is decreased
and the patient is no longer using immunosuppressive drugs
Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell Transplantation,
and/or Radiation cancer therapies in the oral cavity.
American academy of Pediatric dentistry
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Dental care and basic oral cavity hygiene
Mucositis
Mucositis care remains focused on palliation of symptoms
24 Studies on the use of chlorhexidine conflicting results.
Most studies have not demonstrated a prophylactic impact, although reduced colonization of candidial species has been
shown.
24 Patient-controlled analgesia has been helpful in relieving pain associated with mucositis, reducing the requirement for oral
analgesics.
There is no significant evidence of the effectiveness or tolerability of mixtures containing topical anesthetics (eg,
“Philadelphia mouthwash”, “magic mouthwash”).
The use of topical anesthetics often is recommended for pain management although there are no studies available to assess
the benefit and potential for toxicity.
Lidocaine use may obtund or diminish taste and the gag reflex and/or result in a burning sensation, in addition to possible
cardiovsascular and central nervous system effects. Local application may be useful for painful ulcers
The Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology –2007 update guidelines
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Dental care and basic oral cavity hygiene
Mucositis
Oral mucosal infections:
Close monitoring of the oral cavity
allows for timely diagnosis and treatment
of fungal, viral, and bacterial infections.
Prophylactic nystatin is not effective for the prevention and/or treatment of fungal infections
Oral cultures and/or biopsies
of all suspicious lesions should be performed
and prophylactic medications should be initiated until more specific therapy can be prescribed.
The Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology –2007 update guidelines
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Protocol suggestion
The basic components of an oral care protocol include assessment, patient education,
tooth brushing, flossing, and oral rinses. A multidisciplinary, collaborative team
approach is important for implementation of the protocol.
Oral assessment, using a validated tool, also should be conducted regularly to assess
function, pain, and the oral mucosa. The participation of a dentist is recommended
throughout treatment and followup (Multinational Association of Supportive Care in Cancer [MASCC], 2005).
Bland rinses, recognized as an important part of oral hygiene, have not been studied
adequately to meet the criteria for the Recommended for Practice category.
Putting Evidence Into Practice®: evidence-Based Interventions for the Management of Oral Mucositis
Clinical Journal of Oncology Nursing • Volume 12, Number 1 2008
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Protocol suggestion
Clinicians
• Collaborate with a multidisciplinary team in all phases of treatment.
• Conduct a systematic assessment at least daily or at each patient visit. In the outpatient setting, teach
patients to perform oral assessment daily. Teach patients when to report findings to the clinician.
• Provide written instruction and education to patients regarding oral care. Verify understanding with
return explanation and demonstration.
Patients
• Brush all tooth surfaces for at least 90 seconds, twice daily using a soft toothbrush. Allow toothbrush to
air dry before storing. Replace toothbrush on a regular basis.
• Floss at least once daily or as advised by the clinician.
• Rinse mouth four times daily with a bland rinse.
• Avoid tobacco, alcohol, or irritating foods (acidic, hot, rough, spicy).
• Use water-based moisturizers to protect lips.
• Maintain adequate hydration.
Note. Based on information from Dodd et al., 2000; Eilers, 2004; Kwong, 2004; Multinational Association of Supportive
Care in Cancer, 2005; Rubenstein et al., 2004; Scully et al., 2006; Shih et al., 2002.
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Protocol example
-Daily
nursing mucositis evaluation.
-Brushings twice daily with soft bristle toothbrush.
**Foam toothbrush can be substituted if patient is experiencing oral pain**
-Cryotherapy: Ice chips 30 min prior to and throughout Melphalan infusion **Only if patient is receiving Melphalan as part of
conditioning treatment**
-Chlorhexidine gluconate mouthwash: 15 mL swish for 30 s and spit four times daily. **Discontinue at first sign of mucositis**
**After meals and at bedtime**
-Normal saline mouthwash: 30 mL swish for 30 s and spit four times daily
-Caphosol® mouthwash: 30 mL swish for 1 min with 15 mL of the solution and spit out.
Repeat with the remaining 15 mL of the solution and spit out. Repeat four times daily after nomal saline mouthwash.
-Magic mouthwash: 15 mL swish and spit four times daily as needed oral pain
**Initiate at first sign of mucositis*
-Cepastat® lozenges *Sugar Free*: Dissolve in mouth every 2 h as needed oral pain.
At physician’s discretion
Palifermin (Kepivance®
60 mcg/kg/day IV bolus for 3 days with third dose 24–48 h before myelotoxic therapy.
60 mcg/kg/day IV bolus three consecutive days after myelotoxic therapy.
**Palifermin should not be administered within 24h before, during infusion of, or within 24h after administration of myelotoxic chemotherapy*
Post-myelotoxic therapy: Three doses after, with first dose immidiately after HCT infusion, if at least 4 days have elapsed after most recent palifermin administration.
Department of Pharmacy, Mayo Clinic Florida, Jacksonville, FL, USA.
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Protocol example
The following management protocol was recommended :
• Patient education
• Patient-controlled analgesia (morphine in HCST)
• Radiotherapy
– Midline blocks & 3D radiotherapy
– Benzydamine
• Chemotherapy, cryotherapy for
– 30 min before 5-FU
– 20 min before Edatrexate
• Possibly, low level laser therapy
Do not use
• Chlorhexidine
• Aciclovir
• Pentoxifylline.
Minimal care is good oral hygiene plus narcotic analgesics, but a number of other approaches can be helpful (Sonis and Haley, 1996).
Rubenstein et al, 2004.
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Protocol example
Mouth Care for Children and Young
People with Cancer: Evidence-based Guidelines
Guideline Report
Version 1.0 February 2006
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
Conclusion
The focus of oral care protocols is not on specific agents, but on feasibility,
adherence, and patient education.
The protocol also may be specific to patients’ diagnosis and treatment
Some studies in the pediatric setting have demonstrated the superiority of using
protocols over general oral care
The results of this review did not demonstrate superiority of a specific rinse, but
rather, reinforced the importance of oral care
Implementation of a standardized oral care protocol for mucositis management
resulted in a decreased incidence, duration and severity of mucositis, and also
reduced the global negative impact of mucositis.
Future studies may further evaluate the global impact by adjusting for
confounding factors.
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
I believe that
more studies
proposed and conducted
by pediatric nurses,
may help us in our work
in future
The European Group for Blood and Marrow Transplantation
Credits
1.
Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell Transplantation,
and/or Radiation cancer therapies in the oral cavity. American academy of Pediatric dentistry 2008
2. Linee guida per la promozione della salute orale e la prevenzione delle patologie orali negli individui in età evolutiva
che devono essere sottoposti a terapia chemio e/o radio. Ministero della Salute Italiano 2010
3. Putting Evidence Into Practice®:Evidence-Based Interventions for the Management of Oral Mucositis Department of
Pharmacy, Mayo Clinic Florida, Jacksonville, FL, USA. 2008
4. School of Nursing, University of Maryland, Baltimore, USA; HealthQuest, Minneapolis, USA;Colle ge of Dental Medicine,
Nova Southeastern University,Fort Lauderdale, USA ; on benhalf of MASCC / ISOO 2006
5. Eastman Dental Institute, University College London, University of London, London, UK; 2Department of Oral Medicine and
Diagnostic Sciences, Harvard School of Dental Medicine, Divisions of Oral Medicine, Oral and Maxillofacial Surgery and
Dentistry, Brigham and Women’s Hospital and the Dana Farber Cancer Institute, Boston, MA, USA; 3Special Needs Unit,
School of Medicine and Dentistry, University of Santiago de Compostela, Spain 2006
6. UKCCSG-PONF Mouth Care Group 2006
7. the EBMT Prospective Oral Mucositis Audit (POMA) 2007
8. MASCC The Multinational Association of Supportive Care in Cancer Clinical Practice Guidelines: Keefe et al 2007
9. The Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology
10. Monica Fliedner, MSN ANP Oncology, Bern University Hospital (CH) 2010
Paris, 5 April 2011
The European Group for Blood and Marrow Transplantation
The European Group for Blood and Marrow Transplantation